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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t r (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ' ,f`" City-� Lot Size PM Owner's Name Address Phone Contractor ��A _Address �� Lr VA ::? License No, Y_4�149�Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17DESTRUCTION ❑ Y r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑- " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONS "AGR ICU LTURE_VVEL=—'--OTH_ER-WELL"—;PITS/SUMPS }# INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIQNISP IFICATIONS I 4i C1 Industrial El Open Bottom ❑ Manteca Dia. o Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications l`1 Public FI Other [1 Delta Depth of Grout Seal Type of Grout 1. I I Irrigation --Approx. Depth L I rn Surface Seal Installed by - Repair Work Done LJType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 l + Depth i,� .Filler Material IBelow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AQD[TION I I DESTRUCTION I]'(No septic_s.Vst(im permitted if public sewer is 1 w ',: "availably within 200 feet.) e Installation will serve: Residence Commercial , Other? Number of living units: --I- Number of bedrooms 4'f ---�_J c r Character of soil to a depth of 3 feet: '� C�O Water table depth - }� SEPTIC TANK Type/Mfg �d`°� Q�1 - Capacity_124 .� No. Compartments � { � PKG. TREATMENT PLT. ❑ /�� t`Method of Disposal t Distance to nearest: Well Sf90 Foundation _ .._ Pr`operty Line LEACHING LINE X No. & Length of lines �To[ll length/size FILTER BED ❑ Distance to nearest: Well '.._._ Foundation Property Line 1 PA- PITS t� Depth ��Size _ Number { SUMPS ( Distance to nearest: Well 1410 Foundation AGR Property Line o DIS SAL PONDS ❑ 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rides and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not I employ•any parson in such•fnanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant m st call for all required inspe tions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPART-VENT-USE•ONL•Ya-- C-^� ication Accepted by'rT s Dat Area It Grout Inspection by Date�. Final Inspection by Dated' Additional Comment-: ❑ Stk 466-6781 %-❑ LodV 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT RE ITTED CAS RECEIVED BY ATE PERMIT"NO. l INFO 1-4 1 +.EH 113-24 1REV.t/>i 51 � J Eli 14-2e